HomeMy WebLinkAbout2025-00043592 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X60367732/
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and/or Tow Due To Crash YR 2025512025-00043592 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m158 SYMPHONY WAY Elgin02:05
® ❑ RELATED ❑Y ®N 07 06 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ID PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 2 fA
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Ynocencio. Marisela. E. 1 1 /
yr 13-UNDER CARRIAGE FIRE ❑
10 2 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 171
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 ,6•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,,4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7_;—_;__5 *Irves.See Sidebar Ut
Z Saint Charles IL 60174 0 1 0 3372726B IL 2022 REAR
TELEPHONE
IL D 0 3TM LBSJ N9SM 110754 NA ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same NA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
yr Toyota Tacoma 2025 00-NONE 1("I t2..-_, DUETO CRASH ❑ !g 2 x)
o - 13-UNDER CARRIAGE 1 FIRE 0 ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6.TOP 3 9 0
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
s 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 l.'k._ COM VEH D ® Ut
CO
I.* _FIRST CONTACT 2 7 . , _5 •3864790B IL 26 REAR If Yes.See Sidebar 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3TM LBSJ N9SM 110754 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Police Departm 1323239-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 02 / F 2 3 0 1 0
m
/ / #OCCS D
/ / UI OZ D
/ / 0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 18 5 07,06 /2025 02 05 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 18 5 08 99
! / 0 PM• 0 Construction *
Z 3 0 I'i CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME Ynocencio. Marisela. E. 3-707 752169 / / ❑PM SLMT
o U 1 ® 11 5 igi CITATIONS ISSUEDPENDING N ®
0 SECTION CITATION NO. ROAD CLEARANCE TIME
AM• ❑Utility
o r 2 El ARREST NAME Ynocencio. Marisela. E. 11-501-A-2 752168 07/06 /2025 02 06 ❑PM El Unknown work zone type U1 10
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 10
1549-Brown. Bryan 101 331-Ziegler 07 ,25/2025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ''- ' 8ymphony?Way II r INDICATE NORTH Combination):or -I
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L � y _ (example:shuttle or charter bus):or X
,
I 1 designed tocarry 15 fewer passengers and operated a contract carrier O
I- I- --I--•--I r r I - transporting employees Inhe course of their employment example:employee X
II t Not To Scale , } r } transppoortenrg-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L____a____.I VWl - t i. i i ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
.2 XI(example:placards will be displayed on the vehicle).
a D
'I-
CU CARRIER NAME Z
1 ) ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE